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NavMed 369 




1 UNITED STATES N AVY I 



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Rear Admiral Bartholomew W. Hogan MC USN 
Captain Leslie B. Marshall MC USN (RET) 


- Surgeon General 
Editor 




Vol. 33 Friday, 6 February 1959 


No. 3 



TABLE OF CONTENTS 



Historical Fund of the Navy Medical Department 2 

Illness, Life Experiences and Social Environment 3 

Systolic Clicks 6 

Pseudomonas Septicemia 9 

Chemotherapy of Tuberculosis 11 

Treatment, of Papillary Carcinoma of the Thyroid Gland 14 

Salivary Gland Tumors 17 

Early Care of Multiple Fractures 19 

Care of the Patient with Multiple Injuries 22 

Wanted: The Practice of Preventive Medicine 25 

OCS Program for Medical Service Corps 28 

Courses at U.S. Naval Medical School 28 

From the Note Book 29 

SUBMARINE MEDICINE SECTION 

Sport Diving Doctors 31 Nuclear Power Program 31 

Diving Medicine , 32 

DENTAL SECTION 

Mouth Preparation for Removable Partial Dentures 33 

ADA Membership Reaches New High 34 

Applicants Desired for Dental Technician Training 34 

RESERVE SECTION 

Aero Medical Association 34 Promotion Point Credit 35 

PREVENTIVE MEDICINE SECTION 

Parasitic Infestations 36 

Resistance of Beta-Hemolytic Streptococci to Tetracycline 38 

Effect of Alcohol on Risk Taking in Driving 39 




Medical News Letter, Vol. 33, No. 3 



HISTORICAL FUND 

of ihe 

NAVY MEDICAL DEPARTMENT 



A committee has been formed, with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and maintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc., designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D. C. bank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M. D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Department of the Navy 
Washington 25, D. C. 



Committee 

F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L. J. ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary-Treasurer 



Medical News Letter, Vol. 33, No. 3 



Illness, Life Experiences and Social Envir onm ent 

By the beginning of the present decade, there was enough clinical and 
experimental evidence to establish the fact that a man's reactions to the 
situations that he encounters in his daily life may affect a great number of 
his internal processes. In effect, it was clear that any bodily function sub- 
ject to the regulation of the central nervous system might be influenced to 
a significant degree, and that the regulatory influences of the central ner- 
vous system might be mediated directly by way of the neural pathways or 
internal secretions, or indirectly, by way of changes in the over all behav- 
ior of the individual. The effects of these, taken together, might lead to 
notable variations in general activity, energy expenditure, food and fluid 
intake, sleep patterns, and the like, and to important changes in the specific 
demands made upon various organ systems, especially when such systems 
are involuntarily involved in reaction patterns not directly appropriate to the 
adaptation which the organism is attempting to make. In short, a sound 
theoretic and experimental basis supports the old clinical observation that 
disease may wax and wane according to the moods and fortunes of the patient. 

On the other hand, the extent to which such adaptive reactions are 
involved in disease in general and the degree to which they determine the 
health of the individual remained to be established. In an attempt to answer 
some questions in this area, the studies of the relation between human health 
and human ecology which formed the basis for this article were undertaken. 
To the present time, those engaged in these studies have investigated the 
illness patterns of more than 3000 people drawn from the ambulatory popu- 
lation. The subjects fall into five population groups each relatively homo- 
geneous in certain important respects and each selected because an oppor- 
tunity was presented for answering questions pertinent to the over all 
investigation. 

The people studied were: 1700 semiskilled American working women, 
1527 skilled American working men, 100 Chinese graduate students and 
professional people, 76 Hungarian refugees, and 132 recent graduates of 
American colleges. 

Episodes of illness were not distributed at random among the members 
of any of these groups. In each group, during two decades of young adult 
life, one-fourth of the individuals had experienced approximately one-half 
of all episodes of illness that had occurred among all of the people. The 
distributions were such that they can be explained only by assuming that 
some factor in addition to chance operates to determine them. In other 
words, the members of each group behaved as if there were differences in 
their susceptibility to illness. 

These differences in susceptibility to illness were not simply the 
result of differences in susceptibility to one or another specific syndrome. 
In every group, the members displayed a difference in their susceptibility 



Medical News Letter, Vol. 33, No. 3 



to illness in general, regardless of its type or of the causal agents appar- 
ently involved. Thus, as the number of episodes of illness experienced 
by an individual increased, the number of different types of disease syn- 
dromes exhibited also increased. Although a great many syndromes might 
involve one or two organ systems, episodes of illness were not limited to 
a few systems; instead, as the number of episodes of illness experienced 
by an individual increased, the number of his organ systems involved in 
disease increased. Likewise, as the number of episodes he experienced 
increased, he exhibited illnesses of an increasing number of etiologies. 
He was likely to have more "major" irreversible and life -endangering ill- 
nesses as well as more "minor" reversible and transient illnesses. Finally, 
as the nu.nber of his "bodily" illnesses increased, the number of his "emo- 
tional disturbances" and "psychoneurotic" and psychotic manifestations (here 
categorized as "disturbances of mood, thought, and behavior") usually also 
increased. 

These findings have been obtained consistently in each of these five 
groups, regardless of sex, race, culture, economic or social background, 
environment, or life experiences of the people studied. They are most 
reasonably explained by assuming that they are dependent upon factors oper- 
ating within the individual, influencing the ease, the frequency, and the 
degree to which he responds to the great variety of other factors known to 
be capable of causing disease. 

If one examines the illness patterns of men and women over many 
years of their adult lives, one finds that each person has a rather consis- 
tent mean rate of illness episodes around which his annual rate fluctuates. 
However, from time to time, there occur peak periods usually of several 
years' duration during which the episode rate may be much higher. The 
authors call such peak periods "clusters" of illness episodes. If one arbi- 
trarily defines a "cluster year" as a year during which the episode rate 
for disabling illnesses is 1.75 or more times as great as the mean rate for 
the individual over the entire observation period, one finds that, in those 
people who show the phenomenon of "clustering", about one-eighth of the 
years are "cluster years" and that about one-third of each person's illnesses 
occur during such years. 

When one brings together the information derived from this considerable 
number of people of such diverse backgrounds and experience, one can 
scarcely escape the conclusion that whoever a man may be and whatever may 
happen to him the way that he perceives his life' situation and reacts to it is 
an important determinant of his health. It is a reasonable estimate that at 
least one-third of all illness episodes that occurred among these people 
were influenced in their time of occurrence or in their course by the attempts 
of the individual to adapt to the events and situations that he encountered. This 
estimate is based upon the occurrence of "clusters" of episodes and their dem- 
onstrated relation to life experiences. Probably one should add to this the 




Medical News Letter, Vol. 33, No. 3 



evidence that people with a consistently high illness rate experienced a 
majority of all of the episodes that occurred among the group because such 
consistently high rates of illness are at least in part based upon a contin- 
uing inability of the individual to make an adequate adaptation to his milieu. 
When this additional point is considered, it becomes likely that efforts to 
adapt to the social environment are to some degree involved in the majority 
of all illness episodes that occur among the adult population. 

That the state of the host is one of the determinants of the occurrence 
of illness is axiomatic in medicine. The observation that exposure, over- 
activity, extreme fatigue, and other periods of physiologic disturbance may 
facilitate the occurrence of disease or adversely affect its course is as old 
as recorded medical lore. However, it is perhaps not generally appreciated 
that the state of the host is an important determinant of so large a proportion 
of illness episodes and that a man's susceptibility to illness during adult life 
is to such a large degree influenced by his relation to the society in which he 
lives and the people in it. Evidently, all illness is to some extent affected 
by the way that men perceive their life situations and react to them. 

Obviously, some illnesses are influenced in this manner much more 
readily and to a much greater degree than others. Illnesses so easily 
jnfluenced are well known and some of them, such as peptic ulcer and asthma, 
have been called "psychosomatic, " But these studies yielded no evidence 
to support the idea that there is any special category of diseases which should 
be designated by this term. So far as these data are concerned, there need 
be no qualitative difference between peptic ulcer, typhoid fever, carcinoma 
of the breast, and gout in the way that these diseases are related to the 
patient's general adaptation. What ever difference is present appears to be 
only quantitative in that peptic ulcer appears to be more readily, more fre- 
quently, and to a greater extent influenced in its course by the physiologic 
effects of such adaptations. 

The only illnesses in which a disturbance of the adaptation of the indi- 
vidual to his social environment is, by definition, a necessary condition, lie 
in that category which is defined as disturbances of mood, thought, and 
behavior — "sociopathic" or "psychopathic" behavior and perhaps some of the 
psychoneuroses and psychoses. During these studies, it was consistently 
observed that bodily illnesses and disturbances of mood, thought, and behav- 
ior do often occur together, but that there appears to be no causal connection 
between them; it seems rather that both are a part of the response of the man 
to his total milieu, internal as well as external, at a given time. 

The evidence indicates that the reaction of a man to his life situation 
has an influence upon all forms of illness and that it plays a role of signifi- 
cance in at least one-third of all episodes of disease regardless of their 
nature or location, their cause or their severity. Ultimately, medicine will 
have to take account of this in the treatment of illness. It is probable that 
an increasing proportion of therapeutic effort will have to be directed at the 



Medical News Letter, Vol. 33, No. 3 



patient's relation to his environment in order to make any significant im- 
provement in Ms health. In view of the complexities involved in dealing 
with human relationships, human attitudes, and human behavior, and the 
ineffectiveness of present methods of dealing with these factors, it is also 
probable that these efforts will be difficult, time-consuming, and not, at 
first, highly rewarding. The problem stands as a stern challenge to med- 
icine and not as an easy opportunity. (Hinkle, L. E. Jr., Wolff, H. G. , 
Ecologic Investigations of the Relationship Between Illness, Life Exper- 
iences and the Social Environment: Ann. Int. Med., 49: 1373-1387, Dec- 
ember 1958) 

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Systolic Clicks 

This study reviews the subject of systolic clicks or ejection sounds 
and evaluates the authors' material in an endeavor to ascertain their inci- 
dence in various cardiac anomalies constituting basic anatomic deformities 
or underlying hemodynamic states, their relationship to the first heart sound, 
their probable mode of origin and, finally, their diagnostic importance. 

The material utilized for this study is comprised of 809 phonocardio- 
grams on 598 patients of whom 540 were below the age of 16 years. Of the 
598 patients, 146 revealed systolic clicks of one form or another. In addi- 
tion to a complete history, each patient had a thorough physical examination 
with detailed notation of auscultatory findings of the heart, chest roentgeno- 
grams in the anteroposterior and two oblique views, a 15-lead electrocardio- 
gram, and a comprehensive phonocardiogram. In over two-thirds of the 
patients with systolic clicks, the exact nature of the diagnosis was further 
substantiated by 97 cardiac catheterizations, 83 angiocardiograms, 23 
surgical operations, and 16 autopsies. 

Systolic clicks is a worthy, qualitative description of the "sounds" in 
systole under consideration. In rare instances, the clicking character is 
not so evident as mothers. The clicks occurring in early systole which give 
the impression of a split first heart sound, with the second component 
significantly louder than the first or definitely different in character, are the 
more important. These are palpable at times and may be audible all over 
the precordium, but almost invariably have a site of maximal intensity. 
Their selective maximal intensity at the second, and sometimes at the third, 
left intercostal space parasternally, with generally poor or no conduction 
to the apex unless they are loud (significant variation during respiratory 
cycles with evident increase in intensity in expiration, sometimes amount- 
ing to complete absence in inspiration), indicates a pulmonic origin either 
at the level of the pulmonary valve or the pulmonary artery. In some 
instances of severe valvular pulmonary stenosis, the click may be so early 



Medical News Letter, Vol. 33, No. 3 



as to simulate a non-split first heart sound, maximal at the second left 
intercostal space. The aortic clicks are, as a rule, maximal at the apex, 
only occasionally maximal at the third and fourth left intercostal spaces 
parasternally, and rarely maximal at the second right intercostal space 
parasternally. In any case, they are widely propagated over the entire 
precordium. In transposition of the great vessels, an apical early systolic 
click may originate from the pulmonary artery. Either the intensity of the 
aortic clicks is constant throughout the respiratory cycles or the change 
manifested is not remarkable. 

The clicks heard near mid- systole, in mid- systole, or in late systole 
may be single or multiple, do not generally give the impression of any tem- 
poral relationship to the first heart sound, are heard best at the apex or 
lower left sternal border, are usually not heard at the base, are rarely 
loud enough to be palpable, may or may not precede a systolic murmur, 
are apt to be evanescent from one examination to another, usually vary 
with respiration, may significantly change with respect to timing from 
cycle to cycle, and are generally not associated with other significant mur- 
murs or abnormal character or intensity of heart sounds. Such are the 
clicks commonly associated with a normal cardiovascular status. Occasion- 
ally, they may be heard in a definitely abnormal anatomic lesion or hemo- 
dynamic state in which instances their occurrence is likely fortuitous. In 
every one of the present cases, the authors were able to elicit the systolic 
clicks by conventional auscultation. 

Phonocardiographically, the clicks are registered in systole as wave 
forms of comparatively high frequency, of relatively short duration, vary- 
ing from what may appear as a single vibration to rapid multiple vibrations. 
Their amplitude varies directly with their intensity. Because of their fre- 
quency content, the high-frequency or logarithmic records are best suited 
for their delineation. 

Whereas the systolic clicks occurring in mid- systole and late systole 
are of relatively insignificant diagnostic importance, the early systolic 
clicks or ejection sounds undoubtedly are a category apart, for the very 
fact that they occur almost exclusively in abnormal cardiac states. Of 135 
patients with early systolic clicks, 133 had definite cardiac lesions or abnor- 
mal hemodynamic states. Two of the apparently normal patients revealed 
early systolic clicks of the aortic variety and also had what was estimated 
to be a loud aortic closure. This phenomenon may be either a normal var- 
iant or possibly a congenital thickening or fibrosis of the aortic valve leaf- 
lets without manifest stenosis. A similar situation may exist with respect 
to the pulmonary valves. 

On the basis of clinical auscultation and graphic registration, the more 
important early systolic clicks appear to be closely related to the second 
component of a physiologically split first heart sound. Detailed clinical 
and phonocardiographic characteristics of systolic clicks were noted and the 



8 Medical News Letter, Vol. 33, No. 3 



more significant early systolic clicks differentiated from the comparatively 
benign ones occurring just before mid-systole, in mid-systole, and in late 
systole. Clicks of the latter type were encountered mostly in normal 
hearts, but were also found in abnormal states. 

Early systolic clicks were noted to occur in anomalies involving con- 
genital malformations of the stenotic type in the aortic and pulmonary valves 
and in those involving dilatation of the aorta and pulmonary artery. The 
aortic clicks generally tended to be of maximal intensity at the apex and 
varied little during respiratory cycles. The pulmonic clicks were maximal 
at the second left intercostal space parasternally and were loudest during 
expiration, sometimes disappearing completely with inspiration. 

The incidence of early systolic clicks was appreciably high in congenital 
aortic stenosis while they were present in about one-half of the cases of con- 
genital isolated pulmonary stenosis. The latter anomaly in a majority of cases 
was of the mild to moderate type. In these conditions, the early systolic clicks 
always preceded the ejection murmurs. In congenital aortic stenosis, the 
aortic closure was unusually loud in most instances; in congenital pulmonary 
stenosis, a few cases revealed an abnormally loud pulmonic closure. 

Of the anomalies involving the aorta, the early systolic clicks were 
found to be quite consistently present in cases of truncus communis, but were 
also noted in extreme cases of tetralogy of Fallot and only occasionally in 
coarctation of the aorta, transposition of the great vessels, tricuspid atresia, 
aortic regurgitation, and atherosclerosis of the aorta. Dilatation of the pul- 
monary artery associated with Eisenmenger's physiology, Taussig-Bing com- 
plex, and idiopathic dilatation of the pulmonary artery revealed that early 
systolic clicks were a relatively constant finding in these conditions. Pulmon- 
ary hypertension at less than systemic levels and pulmonary dilatation secon- 
dary to large left-to-right shunt with normotensive pressures were sometimes 
noted to be associated with early systolic clicks. 

With respect to timing, the ejection component of the first heart sound 
as well as the aortic clicks, and the concept of isometric rise of aortic pres- 
sure as reflected in simultaneous indirect arterial tracings is discussed. 

The early systolic clicks were considered to be a pathologic manifes- 
tation of the second major, or ejection, component of the first heart sound 
and, depending on their origin, to reflect the isometric contraction period 
or beginning of the, ejection phase of either ventricle. 

In congenital aortic stenosis and valvular pulmonary stenosis, the early 
systolic clicks seemed to originate at the valvular level, occurring after the 
atrio-ventricular valve closure at a mean time interval of 0. 055 and 0. 033 
second respectively. In other conditions, the vessel wall of the aorta or the 
pulmonary artery appeared to be their seat of origin. The mode of occurrence 
of the more benign mid and late systolic clicks could not be ascertained. 

The presence of early systolic clicks was considered an abnormal find- 
ing in itself, and their proper evaluation was regarded as being of significant 



Medical News Letter, Vol. 33, No, 3 



diagnostic importance. Their absence did not imply exclusion of any given 
entity or hemodynamic state. (Minnas, K. , Gasul, B. M. , Systolic Clicks - 
A Clinical, Phonocardiography, and Hemodynamic Evaluation: Am. Heart J. 
57: 49-64, January 1959) 

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Pseudomonas Septicemia 

With the advent of potent antibiotics and other new drugs, the role of 
Pseudomonas aeroginosa as an infectious agent in man has become more 
important. Only scattered reports are available, however, describing 
pseudomonas septicemia and its response to contemporary antimicrobial 
agents. On this account, observations on the clinical therapeutic and mor- 
phologic aspects of pseudomonas septicemia appear to be timely. 

The files of the Bacteriology Department of the Clinical Center, 
National Institutes of Health, were reviewed for patients with blood cultures 
positive for Ps. aeruginosa. An examination was then made of the clinical 
charts and reports of the postmortem cultures of this group. Most of the 
patients had been observed daily and treated by one or more of the authors. 
Autopsies were performed in all of the 22 fatal cases. 

Thirteen of the 2 3 patients were from the acute leukemia service of 
the National Cancer Institute and were selected for special presentation and 
comparison of certain data because their clinical management was similar. 

In 23 patients with pseudomonas septicemia, certain clinical features 
occurred repeatedly. In 5Z%, jaundice developed and 65% had neurological 
disorders. Neurotoxicity with pseudomonas infection has been observed in 
animals and possibly in man. Stevens and co-workers described an 18-year 
old boy who died 66 hours following transfusion of blood contaminated with 
pseudomonas species. The clinical phenomena observed in this patient were 
seen in many of the present patients. Stevens suggested the possibility 
that a "toxin" played a significant role in the patient's symptoms and death 
as antibiotics were effective in sterilizing the patient's blood. In 3 of the 
present patients, antibiotics were effective in sterilizing the blood, but 
clinical improvement did not occur. 

Roily, among other early writers, stressed the presence of a hemor- 
rhagic diathesis and abnormal coagulability of the blood. Numerous reports 
have stressed the fact that severe pseudomonas infections may produce gran- 
ulocytopenia. Experimental work has shown that Ps. aeruginosa or its toxin 
can induce granulocytopenia in animals and injections of endotoxin from 
gram -negative bacteria can produce a similar phenomenon in man. 

Although polymyxin-B is generally accepted as the therapy of choice, 
analysis of sensitivity studies performed on the bacterial isolates from 
these patients showed that, on an in vitro basis, neomycin was superior to 



10 Medical News Letter, Vol. 33, No. 3 



polymyxin-B. The small number of patients treated with neomycin and 
the almost invariably fatal outcome prevented satisfactory evaluation of 
this drug in vivo. Short patient- survival times precluded extended specific 
therapy. In the present series, even the best available antimicrobial agents 
did not affect the rapid and almost uniformly fatal outcome. 

On the acute leukemia service, pseudomonas infections frequently 
occurred in small "epidemics. " The factors responsible are as yet unknown, 
but are under investigation. Epidemics due to Ps. aeruginosa are rare, but 
have been described with relation to infantile diarrhea, omphalitis, and 
gastroenteritis. An epidemic pseudomonas meningitis presumably resulting 
from contamination of medicines has occurred. 

Many factors contribute to lowered host resistance in patients with 
acute leukemia. Among these are granulocytopenia, mucosal bleeding, leu- 
kemic infiltrates of the gums, oral cavity, and intestinal tract, and malnu- 
trition. Antibody response and altered phagocytic properties of abnormal 
leukocytes in these patients have been investigated in this connection. 

Adrenal steroids or adrenocortocotrophic hormone may favorably 
affect the course of severe infections. Conversely, there is evidence, 
particularly in experimental infections, but also in certain infections in 
humans, that these hormones may exert an adverse effect. Millican found 
that cortisone increased the susceptibility of mice to infections with Ps. 
aeruginosa. 

Infections, particularly those due to gram -negative bacteria, frequently 
occur in patients receiving adrenal steroids. Patients in whom pseudomonas 
septicemia developed in the absence of adrenal steroids received no appar- 
ent benefit from their subsequent administration. 

The toxic manifestations of both total body radiation and antimetabolite 
compounds have much in common. Recently, reported experiments have 
shown that mice subjected to radiation frequently died of pseudomonas sep- 
ticemia. The authors' data would suggest that patients treated with anti- 
metabolites, especially those treated to toxicity, are more likely to acquire 
pseudomonas septicemia — a development possibly related to adverse effects 
of antimetabolites on host resistance. In particular, the possibility that 
bacterial seeding may originate in the areas of damaged bowel mucosa must 
be considered. (Forkner, C. E, Jr. et al. , Pseudomonas Septicemia - 
Observations on Twenty-Three Cases: Am. J. Med., XXV : 877-887, 
December 1958) 

* $ jjr * $ $ 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

$ a|e j£ ♦ ♦ ♦ 



Medical News Letter, Vol. 33, No. 3 11 



Chemotherapy of Tuberculosis 

Tuberculosis continues to be a serious infectious disease, and the 
chemical approach to its control has become of ever-increasing importance 
over the past 15 years. Such management is the very foundation of treat- 
ment, rendering the use of general bodily rest, reversible collapse therapy, 
and even sanatorial care of secondary importance. 

This use of drug treatment, however, has not uniformly controlled 
clinical tuberculosis; as a result of increased efforts at case finding, the 
number of new cases of tuberculosis each year remains remarkably constant. 

The ideal characteristics of an antituberculosis agent should include: 
(1) small molecular weight with associated easy diffusibility to the site of 
the infection, (2) tuberculocidal rather than tuberculostatic activity in vivo, 
(3) relative atoxicity to the host, and (4) a slow rate of emergence of resis- 
tant strains of tubercle bacilli. Unfortunately, no antimicrobial has been 
isolated which possesses all of these characteristics, but a number of 
agents have been found to be rather effective in the control of tuberculous 
disease. These maybe divided into the antibiotics and the synthetics. 

All important antibiotics effective against tubercle bacilli are pro- 
duced by soil organisms of the genus Streptomyces. These are streptomycin, 
dihydro streptomycin, viomycin, neomycin, cycloserine, streptovaricin, 
kanamycin, and oxytetracycline. 

Many synthetic compounds have been screened for their antituberculosis 
activity and several groups of substances have been promising. They are the 
sulfones, thiosemicarbasones, aminohydroxybenzoic acids, the derivatives 
of pyridine carboxylic acid, and a few other agents of recent interest. 

The sulfones and thiosemicarbasones are relatively toxic when admin- 
istered for prolonged periods of time. PAS is the principal member of the 
aminohydroxybenzoic acid group. Isoniazid, iproniazid, and pyrazinamide 
are derivatives of pyridine carboxylic acid. Other agents — the thiocarban- 
ilides and hinconstarch — are under study. 

Virulent tubercle bacilli have entered the bodies Of the majority of 
humans on this earth. The portal of entry usually is the respiratory tract, 
although significant infection occurs by way of the gastrointestinal tract. 
Localized infection is established in pulmonary parenchyma or intestinal 
mucosa, but fortunately, the vast majority of individuals satisfactorily 
control this initial insult. A scar, harboring viable tubercle bacilli, 
remains; sensitivity to tuberculoprotein follows; and some degree of 
relative resistance to subsequent infection is acquired. Later events are 
dependent upon many factors which determine whether true reinfection 
with tubercle bacilli from an exogenous source occurs or whether an endo- 
genous exacerbation of disease appears. 

Most patients with active clinical tuberculosis present advanced pul- 
monary disease. The insidious onset and progression coupled with a paucity 



1Z Medical News Letter, Vol. 33, No. 3 



of signs and symptoms frequently fail to alert either the patient or his phys- 
ician to the possibility of tuberculosis of the lungs. Consequently, at the 
time of admission to a sanatorium, some 45% of patients manifest far- 
advanced disease and only 15% or less have but minimal involvement. The 
use of chemotherapy in the treatment of tuberculosis is by necessity directed 
principally at those patients with advanced pulmonary involvement. 

Patients with active tuberculosis of any organ or system of organs, 
confirmed by any of the acceptable methods of which the recovery of tuber- 
cle bacilli is the most precise, are candidates for chemotherapy. The 
choice of drug regimen, the duration of therapy, and the need for other 
forms of management must be made on an individual basis. 

Public health reasons usually render it mandatory that a patient be 
hospitalized, but just as importantly, the best treatment of tuberculosis 
can be effected in a sanatorium where there are special facilities and trained 
personnel for care of the disease. Although great reliance is placed upon 
chemotherapy and there has been modification of programs of rest, strict 
bed confinement is employed usually for patients who have fever or other 
signs of toxicity. Some programs allow free ambulation later. There has 
been de -emphasis of the use of reversible collapse therapy, so that although 
pneumoperitoneum may be employed to some extent, pneumothorax and 
phrenic nerve paralysis virtually have disappeared from the therapeutic 
scene. 

After demonstration of the efficacy, low toxicity, and low incidence 
of bacterial resistance to the regimen of streptomycin and PAS, it became 
established that the ideal chemotherapeutic regimen for the treatment of 
tuberculosis was a combination of two or more drugs given concurrently 
for a long time. Such long-term combination chemotherapy has become 
accepted widely as superior to single drug treatment in sequence. 

The objective of the drug treatment of pulmonary tuberculosis is to 
achieve as much resolution of the reversible components of the disease as 
possible with the least disadvantage to the patient. The use of chemo- 
therapy has been demonstrated to be the most effective means of altering 
the host-parasitic relationship in favor of the host, and although sufficient 
time has not passed to determine the ultimate prognosis of drug-treated 
tuberculosis, early results are most encouraging. 

The efficacy of chemotherapy is limited by the antituberculosis 
activity of the drugs as manifest by clinical response, roentgenologic 
change, sputum conversion, and cavity closure; by the duration of therapy, 
by drug toxicity, and by the appearance of bacterial resistance. 

Active pulmonary tuberculosis under chemotherapy responds quite 
uniformly. With or without the aid of various forms of reversible collapse 
therapy, the exudative components of the disease regress, sputum frequently 
reverts to negative, and a significant number of cavitary lesions close. This 
early goal in the treatment of pulmonary tuberculosis has been designated by 



Medical News Letter, Vol. 33, No. 3 13 



D'Esopo as the "therapeutic target point, " consisting of three parts: (1) re- 
gression and stability of disease by roentgenologic examination of the chest, 
(2) conversion of sputum to negative on culture, and (3) no evidence of res- 
idual cavity. Failure to attain this target point may be a result of persis- 
tently positive sputum or instability of disease, but more likely is due to a 
lack of cavity closure. 

When the target point is not reached, there is little question that sur- 
gical intervention should be considered. Ideally, this would consist of sur- 
gical resection of the residual cavity or other significant disease. The 
smallest subdivision of pulmonary tissue compatible with the removal of 
the significant disease would be removed. There continue to be indications 
for pneumonectomy, but most resections are the removal of lobes, segments, 
or even subsegments or "wedges" of disease tissue. 

An unfortunately large group of patients, who fail to reach target point, 
refuse surgery, have extensive disease or diminished cardiorespiratory 
function which precludes surgical intervention. These must be managed by 
chemotherapy alone and most are treatment failures, although they maybe 
rendered sputum negative for several years before bacteriologic relapse 
occurs. This group of patients — usually males, mostly in the older ages 
and often recalcitrants — pose serious economic and public health problems; 
their prolonged hospitalization seems the only adequate method of their 
control. 

Although the proportion of patients with tuberculosis who represent 
extrapulmonary manifestations of disease is relatively small, they comprise 
an important clinical group. The serious prognosis of miliary and menin- 
geal involvement has called special attention to the effects of chemotherapy 
in extrapulmonary tuberculosis. All forms of active tuberculosis have shown 
favorable response to chemotherapy. Pericardial, enteric, peritoneal, and 
genital tuberculosis are benefited even though surgical intervention may be 
indicated. 

Tuberculosis of the spine, hip, and knee may be controlled by chemo- 
therapy while at local rest, to be followed by the indicated surgical fusion. 
Essentially, no weight-bearing joints can be treated successfully by chemo- 
therapy alone, although some isolated osseous lesions, tenosynovitis, and 
an occasional nonweight -bearing joint can be managed by antimicrobials 
alone. The chemotherapy of orthopedic tuberculosis has shortened mark- 
edly the periods of morbidity and rendered safe the judicious use of surgical 
intervention. 

Renal tuberculosis also responds to chemotherapy. Fewer indications 
for nephrectomy arise and usually adequate protection of the lower urinary 
tract from descending infection can be effected. No great experience has 
been had with INH-FAS, but INH-SM or INH-SM-PAS definitely is superior 
to SM-PAS in converting urine to negative on culture. Continuous chemo- 
therapy appears indicated for a period of at least two years. (Davey, W. N. , 
The Chemotherapy of Tuberculosis: G P, XIX: 107-117, January 1959) 



14 Medical News Letter, Vol. 33, No. 3 



Treatment of Papillary Carcinoma 
of the Thyroid Gland 

Articles can be found in the literature which advocate wide variations 
in methods of management of carcinoma of the thyroid gland. Some phys- 
icians are of the opinion that certain malignant lesions should not be treated 
surgically; some advise only conservative surgical measures, while others 
recommend radical surgery for the same lesions. Generally, it is recog- 
nized that the types of cancer occurring in the thyroid gland vary consid- 
erably in the degree of malignancy. 

In general, carcinomas of this gland can be divided into two groups: 
(1) those of low degree of malignancy, the majority of which are papillary 
carcinomas; and (2) those of high degree of malignancy, the anaplastic car- 
cinomas. The behavior pattern of each group is decidedly different from 
that of the other. For the anaplastic lesions of the thyroid gland, present 
methods of treatment are inadequate and the survival rate is extremely low; 
while for the other group, present methods of treatment — even though vary- 
ing in degree — are adequate and the prognosis is excellent. Because of 
wide variation in prognosis, the types of carcinoma must not be confused 
and must be discussed separately. 

The histologic classification of malignant lesions of the thyroid is, 
as yet, not fully standardized and there may be some disagreement among 
pathologists as to the best method of classifying the more slowly growing 
types of carcinoma. In general, however, there is fairly universal agree- 
ment on what constitutes a papillary cancer of the thyroid. As currently 
defined in the Section of Surgical Pathology at the Mayo Clinic, papillary 
carcinoma is a well differentiated tumor which usually shows a striking 
mixture of papillary and follicular structural components. A few tumors 
are almost completely papillary in architecture, while at the other extreme 
some tumors may be almost entirely follicular and the papillary component 
minimal in amount. Occasionally, a metastatic node may be predominantly 
papillary while the primary lesion is predominantly follicular in architecture. 
These tumors invade parenchymal or extrathyroidal structures and metas- 
tasize primarily to regional lymph nodes and occasionally to distant sites. 

Within the papillary group, considerable variation is apparent in size 
of the primary lesion and the degree of invasiveness of the tumor. Certain 
papillary carcinomas may be minute, even microscopic, and yet be assoc- 
iated with bulky nodal metastasis. These small papillary tumors may be 
detected by the presence of enlarged cervical nodes or may be picked up 
in the course of surgical procedures for other conditions in the thyroid 
gland. It is not considered desirable to make subdivisions within this group 
of small carcinomatous lesions (1. cm. or less in diameter). For the purpose 
of this article, all lesions of this size, although papillary, have been grouped 
under the designation, "occult sclerosing carcinoma. " 



Medical News Letter, Vol. 33, No. 3 15 



Other slowly growing carcinomas of the thyroid including encapsu- 
lated follicular and solid angioinvasive carcinoma, Hurthle cell carcinoma, 
and solid carcinomas with "amyloid" stroma do not show any papillary 
architecture and have been excluded from this study. The present study 
was undertaken to evaluate a series of patients with lesions of papillary 
types. 

As a rule, carcinoma for which surgical treatment is indicated is 
best treated by as radical a surgical procedure as feasible to eradicate the 
primary lesion as well as the primary region of spread. In surgery of the 
head and neck, this rule holds true for squamous cell carcinomas and for 
most adenocarcinomas. However, papillary carcinoma of the thyroid gland 
is, in the opinion of the authors, an exception to this rule. It is a slow- 
growing lesion and if the patient is treated surgically when the lesion is in 
an operable stage, the prognosis is excellent. Even for patients who have 
lesions which are inoperable and who undergo biopsy only or palliative 
resection, the period of survival is prolonged. Many patients live 5, 10, 
or more years before dying of this disease. Distant metastatic lesions 
may be present for many years before causing death. 

The natural life history of papillary carcinoma of the thyroid gland 
and the excellent survival rates as illustrated in the present series of cases 
have made the authors reaffirm their belief that patients having this disease 
do not always have to be treated by radical operation. Although total thy- 
roidectomy and radical neck dissection can be accomplished with a mortal- 
ity rate of less than 1% and with low morbidity, they consider it both unwise 
and unnecessary to extend an operation beyond the limits that will offer the 
patient an excellent chance of survival and cure. Total thyroidectomy 
results in myxedema, a permanent disability. This deficiency is easily 
managed by replacement therapy. Total thyroidectomy also exposes the 
patient to parathyroid tetany which is a severely incapacitating disease which 
also requires prolonged treatment. Martin has said that the seriousness of 
tetany has been overemphasized. In the authors' experience, it has proved 
to be a serious handicap for the patient. In treatment for other types of 
malignant disease, preservation of the parathyroid glands might be insig- 
nificant, but in the management of papillary carcinoma it is not. The glands 
can be identified— in contrast to what has been said— and an attempt should 
be made to preserve some parathyroid tissue unless in so doing gross car- 
cinoma is not removed. 

In 11% of the cases of papillary carcinoma, multicentric lesions are 
present in the thyroid gland. Consequently, the total thyroid gland should 
always be explored. In contrast to what has been said in the literature, 
exploration of the thyroid gland does not jeopardize the success of subse- 
quent dissection in the lateral portion of the neck if such a procedure be- 
comes necessary. The lesions are frequently small and difficult to palpate. 
Because of the occurrence of multicentric lesions, lobectomy should be done 



16 Medical News Letter, Vol. 33, No. 3 



on the side of the known lesion and subtotal lobectomy on the opposite side. 
Admittedly, a small lesion could be left behind in the remnant, but this 
has rarely occurred. When a small portion of thyroid tissue is preserved, 
the development of myxedema is usually prevented and parathyroid tissue 
and the recurrent laryngeal nerve on that side are further protected. If, 
at the time of operation, however, carcinoma is found to be extensive in 
the thyroid, or many lesions are found to be present in the gland, or dis- 
tant metastatic lesions are known to be present, then total thyroidectomy 
should be done. 

In contrast to what has been stated by some, papillary metastatic 
lesions in the cervical lymph nodes remain well encapsulated for long per- 
iods. Apparently, spread is by embolization because invasion into adjacent 
tissues along lymphatic vessels is rarely seen. The truth of these facts 
makes the en bloc dissection of the lateral portion of the neck necessary in 
the presence of squamous cell carcinoma, but not necessary for papillary 
carcinoma. If there is extensive involvement of all groups of cervical 
nodes, then standard radical neck dissection is the only practical method of 
removing the involved regions. However, if only one or several of the groups 
of nodes are involved, then it is the belief that something less than radical 
neck dissection can be done. 

The incidence of nodal metastasis in the present series is 47. 1%. Others 
have reported in the literature an incidence as high as 84. 6%. The authors' 
figure is undoubtedly lower because at the Mayo Clinic they have for a long 
time advised thyroidectomy for asymptomatic nodular goiter. As a result, 
many malignant lesions have been discovered surgically before metastasis 
occurred. 

The practice is to do a neck procedure only when metastatic lesions 
are thought to be present and to extend the operation into the lateral portion 
of the neck only as the findings in this region in each individual case might 
dictate. (Beahrs, O. H. , Woolner, L. B. , The Treatment of Papillary Car- 
cinoma of the Thyroid Gland: Surg, Gynec. & Obst. , 108 : 43-48, January 
1959) 

****** 
Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Navy Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 

addresses. 

****** 



Medical News Letter, Vol. 33, No. 3 17 



Salivary Gland Tumors 

Salivary gland tumors arise chiefly in the parotid and submaxillary 
salivary glands, but may occur in any portion of the oral cavity or respi- 
ratory tract. Mixed tumor and carcinoma are the commonest types affect- 
ing these glands with a small group of miscellaneous tumors also found. 

While mixed tumor is the most common neoplasm affecting the sal- 
ivary glands, in this study one of every five tumors of the parotid and 
more than one -half of the tumors of the submaxillary salivary gland were 
found to be carcinoma. Fifty- seven percent of all tumors of salivary gland 
origin occurring in abnormal locations were carcinoma. This relatively 
high incidence of carcinoma in these tumors is an important observation 
in considering the management of these lesions. The miscellaneous group 
of 59 tumors affecting the salivary glands were made up of a variety of 
lesions with adenocystoma lymphomatosum, or so-called Warthin's tumor, 
comprising 24 of the cases. Other conditions found were cyst, adenoma, 
Mikulicz disease, fibroma, hemangioma, sarcoma, and chronic inflam- 
mation. These conditions are of interest chiefly as a problem in differ- 
ential diagnosis and are sufficiently rare that decision regarding their 
management must be made on the merits of the individual case. 

Tumors of salivary gland origin occurring in sites outside the major 
salivary glands are located almost exclusively in some portion of the oral 
cavity or upper respiratory tract. In this study, 17 patients had tumors 
of salivary gland origin arising in the palate; 10 of these had malignant 
lesions. Other sites affected were the cheek, tongue, lip, antrum, alveolus, 
orbit, epiglottis, and lung. The most effective treatment for mixed tumor 
and carcinoma of salivary gland origin occurring in these abnormal loca- 
tions appears to be radical local extirpation. This may be accomplished 
either by sharp surgical excision with primary closure or by electrosur- 
gical destruction with secondary healing depending on the size and location 
of the lesion. In cases of mixed tumor this treatment should be completely 
effective and in cases of localized carcinoma the cure rate should be high. 

The results of treatment of salivary gland tumors occurring in abnor- 
mal locations are shown. Of the 12 patients with mixed tumor in this group, 
8 were free of recurrence for 5 or more years following surgical removal; 
2 patients were lost to follow-up and 2 received no treatment. Of the 20 
patients with carcinoma of salivary gland origin, 7, or 35%, were living 
and free of disease for 5 or more years following surgical extirpation; 
one patient is still living with disease 6 years after initial treatment; 9 
patients died of their disease in less than 5 years, and 3 patients died of 
other disease in less than 5 years. 

Parotid Gland - Mixed Tumors. The number of patients who first 
present themselves at clinics with recurrence of mixed tumors of the par- 
otid following operation elsewhere suggests tnat enucleation or inadequate 



18 Medical News Letter, Vol. 33, No. 3 



removal of these tumors is rather widely followed. Undoubtedly, this is 
associated with considerable fear of facial nerve injury. In the present 
series, 18% or 27 patients of the total of 149 patients found to have mixed 
tumor of the parotid, had had one or more previous operations. There 
seems to be little question that enucleation of mixed tumor of the parotid 
invites the possibility of recurrence and that if the parotid tumor is found 
to be carcinoma on pathological examination, the best chance of effecting 
a cure is lost. 

The most successful treatment of mixed tumor of the parotid appears 
to be a complete removal of the tumor with as generous a portion of the 
parotid gland as the situation permits. To carry this out and to minimize the 
the possibility of facial nerve injury, the operative procedure must include 
a dissection of the nerve trunk and its major branches. This may be accom- 
plished by a direct approach to the main trunk of the nerve or by locating 
a major branch and following this back to the main nerve trunk. 

Unfortunately, nearly one -quarter of the patients with carcinoma of 
the parotid and submaxillary salivary glands seen at hospitals by the authors 
had advanced inoperable disease. The majority of these patients had had 
deep x-ray therapy, with about 50% showing varying degrees of regression 
of their disease for a few months to 2 years. 

More recently, the authors have found that malignant tumors of sal- 
ivary gland origin may be favorably influenced either by hormones or by the 
combination of hormone and x-ray therapy. This clinical experiment was 
based on observations made by Nathanson and White who found that increased 
radiation response could be induced in breast carcinoma by prior adminis- 
tration of estrogen. The application of this finding to salivary gland cancer 
was prompted by the observations of sex differences in the submaxillary 
glands of laboratory animals. 

Radical excision with exposure of the facial nerve in all tumors of the 
parotid gland should minimize the danger of facial nerve injury, should 
result in few, if any, recurrences of mixed tumor, and should be adequate 
treatment for carcinoma in its early stage. 

In carcinoma of the parotid, failure to establish the diagnosis in early 
cases results in the employment of subradical procedures and invites recur- 
rence. When regional lymph node metastases are established, the oppor- 
tunity for cure is markedly decreased. 

All tumors of the submaxillary salivary gland should be considered 
as malignant. In proved carcinoma only, the most rigorous primary sur- 
gical attack to Include radical neck dissection will improve the results in 
this disease. 

The management of tumors of salivary gland origin in abnormal loca- 
tions presents an individual consideration. A large number of these tumors 
are malignant and a radical initial surgical extirpation in early cases should 
result in a high percentage of cures. 



Medical News Letter, Vol. 33, No. 3 19 



Irradiation in. the form of deep x-ray therapy affords palliation for 
varying periods in about 50% of the patients with advanced cancer of the 
salivary glands. 

Finally, estrogen alone or estrogen combined with x-ray irradiation 
appears to have a place in the palliative treatment of advanced cancer of 
the salivary glands and further investigation of this method of treatment 
seems indicated. (Garcelon, G.G. , Salivary Gland Tumors - Management 
and Results: Arch. Surg., 78: 12-16, January 1959) 

Early Care of Multiple Fractures 

This discussion concerns itself with three major points: (1) evaluation 
of the patient, (2) systemic and local alterations in the patient with multiple 
fractures, and (3) treatment program. It is not designed to introduce any- 
thing particularly new; rather, it is intended to bring into focus certain con- 
cepts of treatment which are either frequently forgotten or not universally 
known. 

For convenience of discussion, a case of multiple fractures is defined 
as any patient with fracture of more than one major long bone. Many per- 
sons who have such fractures will also have associated injuries to the head, 
thorax, or abdomen; in some, the fractures will be a secondary problem. 
Therefore, initial evaluation of the patient with multiple fractures must 
include a critical appraisal of the patient's general condition, his vital signs, 
and the extent of all associated injuries. During this early period of eval- 
uation, it is essential that there is an adequate airway and that hemorrhage 
and shock are under control or are being combated. 

An accurate picture of the patient's total problem can best be secured 
through the team approach. When feasible, appropriate members of in- 
volved surgical specialties should be enlisted to evaluate all phases of the 
patient's injuries. The over all management of the patient during evaluation 
should be handled as suggested by McCarroll by that member of the team 
whose specialty concerns itself most imminently with the welfare of the 
patient. In this regard, except for life -threatening hemorrhage from major 
arterial damage to the extremities, fracture care per se takes low priority. 
Even in the case of open fractures, definitive orthopedic care must await 
treatment of other more urgent problems involving the head, thorax, and 
abdominal viscera. Diagnostic roentgenographs studies of the extremities 
are contraindicated until the patient becomes predominantly an orthopedic 
problem or until it is deemed safe to proceed with definitive fracture care. 
During the early period of total patient evaluation, splinting of fractures can 
be easily accomplished without the need or benefit of x-rays. 



20 Medical News Letter, Vol. 33, No. 3 



Changes which occur in the patient with multiple fractures are both 
local and systemic. The local changes are variable and deal essentially 
with principles of individual fracture care. The systemic changes are 
rather constant in their occurrence in every patient of this type and may 
be grouped as to type and time of occurrence as follows: 

I. Early systemic changes (up to 48 hrs. ) 
A. Circulatory changes 

1. Severe blood loss (which may lead to shock) 

2. Shock due to trauma to tissue or neurogenic factors 

II. Late systemic changes (after 48 hrs.) 

A. Renal dysfunction 

B. Metabolic changes 

1. Protein 

2. Carbohydrate 

3. Mineral 

In view of the discussion of the changes which occur in the patient 
with multiple fractures, a treatment program is outlined. The principles 
governing the dare of such a patient can be divided into those of a local and 
of a general nature. The local treatment of individual fractures is not an 
essential part of this discussion, but it is worth while to emphasize that 
proper splinting of fractures is essential to prevent the development or 
aggravation of shock; it will serve as adequate local treatment while the 
general condition of the patient is evaluated and restored to an acceptable 
state. In addition to splinting, first aid treatment of local open wounds 
of the extremities maybe accomplished. During the resuscitation stage, 
this consists simply of control of hemorrhage and application of sterile 
dressings in order to avoid secondary contamination. Judiciously applied 
compression dressings are also of help in controlling interstitial hemor- 
rhage and edema. 

The program of general supportive care is headlined by the all- 
important principle of maintaining an adequate airway in order to preserve 
a live patient. The indications for tracheotomy should be carefully weighed 
and if injuries to the face, chest, or head compromise a free exchange of 
air, tracheotomy should be performed without hesitation. 

Analgesics and narcotics for the control of pain are often essential in 
order to prevent aggravation of shock. In the presence of minor injuries to 
the head when the patient is conscious, Demerol or codeine may be given for 
pain. However, each case must be critically individualized in the event of 
associated severe injuries to the head. The administration of morphine 
should be avoided in any case because of its miotic effect which deprives the 
surgeon of a helpful aid in evaluating injuries to the head. 



Medical News Letter, Vol. 33, No. 3 2i 



Because nearly every patient with multiple fractures is either in some 
degree of shock or is in impending shock as a result of circulating blood 
loss and other factors, replacement therapy must be started at once. It is 
far better to anticipate the development of shock and treat it prophylactically 
than to wait for it to occur. This is particularly true if subsequent surgery 
is anticipated. In the case of fractures, whole blood is the substance of 
choice, but plasma expanders, such as dextran or serum albumin may be 
used early when blood is not available. If the patient is in shock, replace- 
ment therapy should continue until blood pressure and pulse have returned 
to a reasonably normal level and are stable. In those cases of impending 
or potential shock, replacement therapy should be given according to esti- 
mates of blood loss. 

Following resuscitation and general supportive therapy, it is the res- 
ponsibility of the fracture surgeon to conduct a thorough examination of the 
patient's musculoskeletal system. Diagnostic x-ray studies are now per- 
missible and these should be as complete as the patient's condition and 
transportability allow. 

As soon as the condition of the patient allows, all open wounds must 
be treated as emergencies. This is particularly urgent in the case of open 
fractures where the threat of disabling chronic bone infection is so real. 
In these days of drug -resistant staphylococcal infections, even the ultimate 
outcome of the patient's life may depend upon proper early care of these 
open wounds. Thorough debridement and cleansing according to sound sur- 
gical principles is essential; whether the wounds are closed primarily or 
secondarily will vary with the local problem as well as with the individual 
surgeon. The goal is to convert all open wounds into clean closed wounds 
as soon as possible. 

In all patients having sustained severe injuries, particularly those 
with excessive damage to soft tissues, those having preexisting renal dis- 
ease, and those of older age groups, careful attention must be paid to the 
amount of urinary output and its specific gravity. Fluid intake and output 
must be accurately charted. The possibility of severe renal dysfunction is 
always present following severe trauma and development must be anticipated, 
recognized, and treated because, if unrecognized or improperly treated, 
renal shutdown with its resultant alterations in fluid and electrolyte balance 
may lead to a fatal outcome. 

A concept often overlooked in the care of this type of patient is that 
of reevaluation. It is not uncommon for major joint derangement or some 
other significant injury to an extremity to go unnoticed for a long period 
simply because at the initial examination, the patient's and surgeon's atten- 
tion were drawn elsewhere. Failure to recognize associated trauma can be 
obviated by repeated thorough physical examination of the patient at regular 
intervals. 

Last, but not any less important, is treatment of the psychological 
aspects of the patient having sustained multiple fractures. This applies in 



22 Medical News Letter, Vol. 33, No. 3 



particular to those individuals whose injuries will demand prolonged immob- 
ilization and extensive rehabilitation. This important aspect of treatment 
must constantly be kept in mind to the extent that all such patients are given 
daily prophylactic psychotherapy by their doctor in the hope of avoiding the 
development of more complex and recalcitrant mental conditions requiring 
aggressive and costly psychiatric care. (Coleman, S. S. , Early Care of 
the Patient with Multiple Fractures: Am. J. Surg., 97: 43-48, January 1959} 

* % :$! jjt j{c & 

Care of the Patient with Multiple Injuries 

There can be no rigid rules for the management of all extensively 
injured patients. The early recognition and management of important unsus- 
pected lesions, however, will help to prevent additional superimposed trauma 
which, in itself, may make the difference between life and death or between 
mere survival and independence. The most important immediate problems 
consist of recognizing or establishing an adequate airway, preventing further 
hemorrhage, replacing blood, and avoiding damage by injudicious movement 
of the patient. 

Immediate Measures 



The movement of the patient from the site of injury can, in itself, be 
the actual cause of death. Movement and transportation is best undertaken 
by trained persons. Transportation of fracture cases with the simplest 
type of side -splinting is probably the best. The control of hemorrhage by 
direct pressure compression bandages as opposed to a tourniquet is prob- 
ably also best. Movement of the patient from the site of injury to the 
hospital should not be done with speed but with great care and gentleness. 
Sudden starts and stops, bouncing over rough roads, and swerving around 
corners should be avoided. 

Extablishment of Extent of Injury . The physician who first examines 
the patient should do a complete systematic rapid physical examination. As 
with any physical examination, looking for the normal immediately reveals 
the abnormal. He should look, he should feel, he should smell (alcohol, 
vomitus, feces, urine, and-acetone), and he should listen. 

A simple recording of the clinical findings is essential because the 
clinical course of the patient and progressive changes of signs and symp- 
toms are often the actual key to correct diagnosis. Recording of negative 
findings is important as they may later become positive. This is particular- 
ly true of intra-abdominal, head, and chest injuries. 

Certain traumatic conditions may be obvious. However, some serious 
injuries are at times undetectable on initial examination. Visceral injuries 
of this nature frequently manifest themselves hours after the initial trauma. 



Medical News Letter, Vol. 33, No. 3 23 



They should, be suspected and specifically looked for in order for the phys- 
ician to be ahead of their devastating possibilities if they are found out too 
late. 

The orthopedist is taught to suspect a combination of injuries in 
certain types of trauma. For example, a fractured patella and dislocation 
of the hip are often combined. The os calcis fracture is also often assoc- 
iated with a central dislocation of the hip or a fracture of the spine or of 
the base of the skull or both. A crushed pelvis is frequently combined with 
a rupture of the posterior urethra. Chest injuries are often associated with 
a ruptured spleen or a diaphragmatic hernia. Penetrating chest wounds are 
associated with injuries involving abdominal viscera. These combinations 
should be considered in order not to be overlooked. 

Asphyxia, severe hemorrhage, and shock are common features in mul- 
tiple injury cases. Immediate recognition and treatment are necessary. Open 
airway is essential to life and should be established at once. Simple man- 
ipulation of the tongue, mandible, or both, or changing the position of the 
head and neck may be all that is necessary. Suction or wiping out the upper 
airways may be used to remove blood or mucus from respiratory passages. 
At times, however, a tracheotomy may be indicated. In those patients who 
do not have a cough reflex for clearing the upper air passages, suction and 
the administration of oxygen through a tracheotomy tube may be necessary. 

Gross hemorrhage is the most common and often the simplest of all 
the conditions to alleviate. The application of local pressure, the use of 
a hemostat, and tying off the bleeders are the usual methods of controlling 
bleeding. Concealed hemorrhage in the thorax, abdomen, or retroperito- 
neal space may cause death. In the severely injured patient, blood replace- 
ment therapy should be initiated at once and while replacement of blood is 
being brought about a more careful evaluation of the patient is easier and 
more surely apt to save his life — continued massive hemorrhage is not 
compatible with life for even a short duration of time. 

As soon as an adequate airway has been established, hemorrhage 
arrested, and blood replacement started, the obvious fractures should be 
splinted to prevent further trauma and shock. Major fractures, strangely 
enough, are commonly overlooked. Minor fractures and, frequently, dis- 
locations of the major joints may be undetected. 

Shock of some degree is associated with all multiple injuries. The 
main cause of shock is often loss of circulating blood volume. Replace- 
ment therapy, to be effective, must be prompt. It is best done by the use 
of whole blood, which increases circulating fluid volume, as well as the 
number of erythrocytes, to handle oxygen requirements in the tissues. 
Saline solution is invaluable as a temporary agent for raising the blood pres- 
sure only while awaiting plasma or whole blood. It should be used only in 
emergencies because it leaves the circulation rapidly and takes plasma 



Z4 Medical News Letter, Vol. 33, No. 3 



protein with it. Trendelenburg position of the patient, elevation of the 
extremities, and the administration of oxygen are all useful adjuncts. 

Some of the diagnostic problems are clarified through a complete 
history and a careful physical examination. The knowledge of the mechan- 
ism of injury may give a real clue to concealed pathological changes. The 
obvious injuries must not divert the concentration of the careful examiner 
and thus allow him to overlook other conditions, such as serious spinal, 
intra-abdominal, or intrathoracic injuries. Fractures of the extremity or 
bleeding from head lacerations often attract attention to such a degree that 
frequently these are investigated too thoroughly by x-ray and other studies 
while the less obvious but infinitely more important areas and serious 
internal injuries may be undetected. 

The physical examination must be quick, gentle, and without undue 
exposure. X-Rays should be taken only when necessary and with minimum 
movement of the patient. It is possible for movement from a stretcher to 
an x-ray table to produce a profound circulatory collapse. 

Initial Management of Specific Types of Injury. Chest injuries require 
priority in treatment of any serious disturbance of the cardiovascular phys- 
iology. Potential bronchial secretions, sucking wounds, pneumothorax, 
massive bleeding into the pleura, and cardiac tamponade all may lead to 
profound cardiorespiratory changes requiring immediate treatment. Tho- 
racic injuries should be treated before other operative procedures are 
undertaken, and when combined abdominal-thoracic injuries are encountered, 
the thoracic portion is undertaken first. 

Blunt and penetrating types of trauma may produce various types of 
lesions in the abdomen. A careful local examination of the abdomen should 
be undertaken, particularly in an unconscious patient. All penetrating 
wounds of the abdomen should be explored as soon as the patient's general 
condition permits. Watchful waiting is dangerous. Blunt injuries to the 
abdomen may be serious. / ruptured spleen or bladder, laceration of the 
liver or intestine, mesenteric hemorrhage, or injury to the pancreas may 
present diagnostic difficulties. Lacerations of the kidneys and serious 
retroperitoneal hemorrhage maybe associated with injuries to the spine. 

Urine specimens should be obtained promptly in all seriously injured 
patients. The presence of blood indicates some injury; however, the degree 
of hematuria is not necessarily indicative of the degree of the damage. Most 
urinary injuries can be treated conservatively. Rupture of the ureter, blad- 
der, and urethra require early initial repair to prevent urine extravasation. 

Peripheral nerve functions should be determined in examining wounds 
of the extremities. Simple tests for nerve injuries in both the upper and 
lower extremities are well known and detection is relatively easy. 

Debridement of open wounds, reduction and immobilization of frac- 
tures, early amputation of all devitalized parts, and other procedures all 
play a major part in the rehabilitation of the extensively injured patient. 



Medical News Letter, Vol. 33, No. 3 25 



The use of a broad-spectrum antibiotic and whole blood, debridement of 
devitalized tissue, and the use of prophylactic antitetanic serum and toxoid 
therapy are important. (Aufranc, O. E. , Care of the Patient with Multiple 
Injuries: J. A.M. A. , 168 : 2091-2094, December 20, 1958) 

(OccMedDispDiv, BuMed) 

Wanted: The Practice of Preventive Medicine 

The term preventive medicine is fundamentally concerned with health 
problems of the individual. Preventive medicine deals with the immuniza- 
tion of the individual against certain communicable diseases, the state of 
his nutrition, the early treatment of incipient disease, and the application 
in each case of the available skills of medicine and surgery and of community 
organization for the prevention of the sequelae of serious illness. 

The summons to the practice of preventive medicine is evident in the 
continuing existence of acute infectious, chronic, and mental diseases; in the 
findings from medical surveys of ostensibly healthy people; and in the character 
of demands on physicians, hospitals, and other agencies concerned with health. 

Infectious disease is still a world wide health hazard, causing more 
than one-half of the deaths and probably an even higher proportion of the 
sicknesses of mankind. An appreciable morbidity and mortality rate con- 
tinues for various forms of pneumonia and other respiratory infections, 
meningitis, septicemia, intestinal infections, and numerous virus diseases. 
Many communicable diseases are yet uncontrolled, even though basic know- 
ledge would appear to allow successful control. 

The older age groups, among whom the chronic diseases have long 
been a major health problem, now constitute 10% of the population. Their 
number increases yearly. The four most common and serious threats to 
life in later years are: (1) blood vessel breakdown, (2) cancer, (3) arth- 
ritis and rheumatism, and (4) nervous and mental disorders. In all of 
these threats, it appears that two basic factors are significant: (1) nutrition, 
and (2) prolonged stress or exhaustion. Both the investigation and applica- 
tion of promising forms of prevention of disorders of aging patients require 
attention. 

Approximately half of the nation's hospital beds are said to be occu- 
pied by patients with mental disease. One of every 20 adults is likely, at 
some time during his lifetime, to be a patient in a mental hospital; and 
additional one or two of that number at some time will be substantially dis- 
abled by mental disabilities which do not require care in an institution. 

The records of the Veterans Administration Hospitals suggest that 
the incidence of severely handicapping emotional disturbances is high. 
Estimates are that 20 to 25% of industrial workers are maladjusted. They 



26 Medical News Letter, Vol. 33, No. 3 



.ire either dissatisfied with their work, unhappy at home, angry with the 
boss, disturbed by financial insecurity, or just plain unstable. There is 
reason to believe that the so-called minor emotional disturbances, unless 
corrected, are potent producers of subsequent human misery and inefficiency. 

The results of health surveys of workers show a need for more effec- 
tive practice of preventive medicine. In one industry, more than half of 
the workers had errors in visual refraction, nearly a third had dental caries 
and gingival infection, and an appreciable number were obese or had mal- 
nutrition, psychoneurosis, or anemia. 

The shortage in the working force — all of it, from the supercharged 
Phi Beta Kappas to the laborer in the bull-gang — constitutes a demand for 
any step which keeps the workers on the effective list. Substantial absences 
from work cannot be tolerated. Once upon a time, vacancies could be filled 
by shifting a few men or hiring extra workers to perform hand operations 
that practically anyone could do. Currently, most of the workers are spec- 
ialists, trained to operate complicated equipment. The capital investment 
per employee has increased rapidly (automation); this investment now is so 
large in some industries that the illness of a single worker may be as costly 
as the absence of a movie star in the shooting of a big film. 

Trends in the character of service provided by community hospitals 
point to an increasing recognition of the role of prevention. Such develop- 
ments are: diagnostic clinics, consultation services, periodic examinations 
for the ostensibly well persons including screening procedures, child wel- 
fare and child development clinics, prenatal and postnatal clinics, preven- 
tive dentistry and oral hygiene, follow-up clinics, nutritional advice and 
supervision, social service departments, and programs for convalescent 
care and home care. These developments have their raison d'etre and 
their accomplishments in health maintenance. 

There must be wider clinical practice of preventive medicine because 
the job cannot be done alone by those specializing in public health, pedia- 
trics, industrial medicine, or in other forms of practice concerned with 
preventive medicine in particular. Some such specialized forms of prac- 
tice do not provide the personal contact with the patient which is needed 
if certain disease processes are to be avoided. 

The clinical practice of preventive medicine is, of necessity, the 
answer to obesity. The few corpulent persons who do achieve and maintain 
an optimal weight usually do so under guidance of a personal physician — 
not because the fountainheads of nutritional knowledge say obesity is a 
serious health hazard. Thiamine deficiencies can be prevented by adding 
thiamine to bread, but unneeded calorie consumption cannot be prevented 
by any action on the part of the flour mill, low calorie "health breads" 
notwithstanding ! 

How well is the practice of preventive medicine doing, and what are 
its roadblocks? Much of current practices by physicians is actually in the 



Medical News Letter, Vol. 33, No. 3 27 



field of prevention. The physician who provides sound nutritional help 
for his patients, quietly educating, countering the claims of food faddists 
and purveyors of special nostrums offered for nutritional purposes, is 
practicing prevention of disease. The gastroenterologist is practicing 
prevention when he stops the habitual use of cathartics by the patient with 
a bellyache and thus allows the patient's colon to fill and empty, to function 
as a normal and pain-free structure. The cardiologist does the same when 
he instructs the rheumatic fever patient in the control of group A beta hemo- 
lytic streptococcal infections. The excision of precancerous lesions of the 
skin, premarital instruction, and judicious attention to anxiety states, 
likewise are accepted phases of preventive medicine. 

The great majority of doctors would welcome an opportunity to take 
an active part in disease prevention, but they are so snowed under with 
routine treatment of trivialities that the urge quickly dies and consciences 
become hardened. Physicians accept prevention of illness and injury as a 
worthy desideratum. Why the lag and frustration in prevention? Examine 
some practical reasons why more professional lives are not spent in the 
millennium of prophylaxis. Awareness of this is necessary to cope with 
the responsibilities. 

There is a lag in applying "know-how" in human affairs. There are 
many experiences to show that one, two, or more generations may elapse 
before significant health knowledge gleaned from a laboratory or reported 
from clinical experience is widely and effectively applied. Chlorination 
of drinking water had to be sold — now fluoridation. Garland has called the 
phenomenon "unassimilated progress. " Aside from a continuing need for 
more knowledge, many of the difficulties of any generation arise from its 
failure to apply the knowledge which it actually possesses; thus, unassimi- 
lated progress in avoiding disease. 

The influence of housing, air pollution, working conditions, climate, 
temperature, light, color, and noise are said to be important to health. 
Exactly what is known about the operation of these factors? 

Preventive medicine should not be isolated from the main current 
of medicine for training purposes. The student learns in practice that 
many phases of a physician's responsibility go hand in hand. Because the 
pediatrician has learned to stress the normal development of children and 
the avoidance of disease as his best contribution, there seems to be hope 
that practitioners of other specialties can broaden their interests and, 
delight in the recognition and encouragement of health along with the cure 
of disease in their patients. (McGee, Lt.C 4 Wanted: The Practice of 
Preventive Medicine: Postgrad. Med., 2_4: 475-481, November 1958) 

(OccMedDispDiv, BuMed) 

5j? j}: >}: s^ ^! 3jc 



28 Medical News Letter, Vol. 33, No. 3 



OCS Program for Medical Service Corps 

A limited number of vacancies in the Medical Service Corps will be 
filled by appointment of qualified enlisted applicants to the grade of Ensign, 
2305 (Supply and Administration Section). Eligible enlisted members of 
the naval service on active duty (HMC's, DTC's, HMl's, andDTl's) 
may apply to the Chief of Naval Personnel (Pers-B6221) under the Officer 
Candidate School Program described in BuPers Instruction 1120.29. 

Selected enlisted applicants will be ordered to the U. S. Naval Schools 
Command, Newport, R. I. , designated as officer candidates within their 
present pay grades, and provided a 4 months' indoctrination course. Upon 
successful completion of indoctrination, selected candidates will be appoint- 
ed as Reserve officers in the grade of Ensign, Medical Service Corps and 
will be required to serve on active duty in commissioned grade for 3 years 
from date of acceptance. Opportunities will exist for voluntary extensions 
of active duty in accordance with the needs of the service and it may be 
possible for some outstanding officers to augment into the Regular Navy. 

It should be noted that this program is not related to the annual in- 
service procurement program for Regular Navy as outlined and described 
in BuPers Inst. 1120. 15C. Significantly, candidates for the OCS program 
may be either USN or USNR, may be eligible up to age 34-1/2 at time of 
application and are not required to compete in Officer Selection Battery 
and written professional examinations. (MSC Div, BuMed) 

# sj: :jc %z ^ )J: 

Courses at U. 5. Naval Medical School 

A short tutorial course in Bacteriology will be given at the U. S. Naval 
Medical School from 9 to 13 March 1959, inclusively. The course is de- 
signed to acquaint personnel of the Navy assigned to clinical laboratories 
with certain new procedures and techniques as applied to biochemistry. The 
components of the course will consist of identification of pathogens through 
fluorescent antibody techniques, isolation and identification of staphylococci 
and a cytochemical test for Mycobacterium tuberculosis. Also included in 
the course will be a discussion of current trends in clinical mycology 
laboratory and visits to laboratories and other departments of the Naval 
Medical School 

The type of instruction provided will be that of practical laboratory 
exercises and demonstrations supplemented by discussions. 



Also to be given from 16 to 20 March 1959 inclusively is a short course 
in Parasitology. The purpose of this course is to acquaint Medical officers 



Medical News Letter, Vol. 33, No. 3 29 



and Medical Service Corps officers assigned to laboratories, particularly 
in parasitology, with a current evaluation of diagnostic procedures, epi- 
demiology, pathology, prophylaxis and treatment of intestinal parasites 
and blood and tissue parasites. Included in the course also will be the 
identification of intestinal parasites such as protozoa, trematodes (including 
liver flukes), cestodes, nematodes. In addition, practical exercise in diag- 
nosis and recognition of blood and tissue parasites, such as plasmodia, 
trypanosomes, leishmania, trematodes, cestodes and nematodes. 

Instruction in the above course in parasitology will consist of practical 
laboratory exercises in diagnosis, recognition, demonstrations, lectures, 
and discussions. 



Application for either course should be submitted in accordance with 
current directives. Eligibility is necessarily limited to officers of the 
Medical Corps and Medical Service Corps assigned to laboratories. Requests 
from interested personnel must be received in the Bureau of Medicine and 
Surgery prior to 20 February 1959. (ProfDiv, BuMed) 

$: $ sjs ;$ $ j)i 

From the Note Book 

1. Flag officers of the Navy Dental Corps attended a conference at the Dental 
Division, BuMed, January 26-28, 1959, to discuss programs and policies 
for the Navy Dental Corps for the coming year. (TIO, BuMed) 

2. CAPT R. B. Wolcott DC USN, U. S. Naval Training Center, Bainbridge, 
Md. , recently presented a lecture entitled "Amalgam Treads Among the 
Gold" at the meetings of the Lincoln, Nebraska Dental Society and the 
Omaha, Nebraska District Dental Society. (TIO, BuMed) 

3. CAPT A. K. Kaires DC USN, U.S. Naval Station, Sangley Point, P. I. , 
recently presented a lecture on M A Coordinated Plan for Prosthodontic 
Treatment" at the meeting of the Philippine Dental Association in Manila. 

(TIO, BuMed) 

4. Two of the paths for an enlisted man to take for a commission in the 
Navy are under the Navy Enlisted Advanced School Program and the Navy 
Enlisted Scientific Education Program. It is planned that up to 600 enlisted 
men will be selected annually for college training leading to baccalaureate 
degrees. (NavNews, January 15, 1959) 

5. The U. S. Navy Medical Research Unit No. 2 reports that the Asian 
variant influenza strains isolated early in December from the epidemic 



30 Medical News Letter, Vol. 33, No. 3 



occurring in Taiwan appear to be "identical antigenically with the April 
1957 and November-December 1957 strains. " No outbreaks of respiratory 
disease confirmed as influenza by isolation of virus have been reported in 
the United States so far this winter. (PHS, HEW) 

6. During a period of 15 months, 474 cases of anemia in late pregnancy 
and the puerperium were investigated by sternal puncture, blood counts, 
and serum-iron estimations. In 90 cases a megaloblastic marrow was 
found, 28 of them in the puerperium. All cases were treated with folic acid. 
The reticulocyte peak and the drop in the serum -iron level reflected the 
response to treatment in a majority of patients. (The Lancet, 27 December 
1958; C. Giles, E. M. Shuttleworth) 

7. The course of 30 patients whose diagnosis of documented primary hyper- 
tension was established prior to 25 years of age is described. The results 
do not support the view that the disorder is necessarily more severe when it is 
contracted in youth. (Ann. Int. Med. , December 1958; G. A, Perera, M. D. 

8. The designation mucocutaneous -ocular syndrome is used in this article 
as a general collective term to include Behcet's syndrome, severe ery- 
thema exudativum multiforme, Stevens- Johnson syndrome, and ectodermosis 
erosive pluriorificialis. These syndrome s sometime s involve internal organs. 
Usually the respiratory tract or the central nervous system is affected but 

a review of the literature reveals that involvement of the gastrointestinal 
tract is not infrequent. (Am. J. Med. , December 1958; J. Bfie, M. D. , 
J. B. Dalgaard, M. D. , D. Scott, M. D. , Bergen) 

9. Kanamycin, a broad spectrum antibiotic, isolated from cultures of 
Streptomyces kanamyceticus by the Japanese, has been evaluated as an 
agent for intestinal antisepsis. Kanamycin is one of the most effective 
agents yet studied for preoperative preparation of the colon. (Surg. 
Gynec. &Obst., January 1959, I. Cohn Jr. , M. D. , A. B. Longacre, M. D. ) 

10. This article discusses briefly some of the problems in the surgical 
treatment of biliary tract disease and suggests a classification of the stages 
of biliary tract disease as encountered at operation. (Am. J. Surg., January 
1959; F. Glenn, M. D. ) 

11. Postoperative chronic osteomyelitis of the hip joint in adults is discussed 
in Arch. Surg., January 1959; J. Michels, M. D. et al. ) 

12. The diagnosis and treatment of psychocutaneous disorders are discussed 
inGP, January 1959; P.F.D. Seitz, M. D. 

Sjc $ $ $ %L $ 



Medical News Letter, Vol. 33, No. 3 31 

SUBMARINE MEDICINE SECTION 




Sport Diving Doctors 

There will be a few openings in July 1959 for doctors having an inter- 
est in sport diving to serve with units engaged in underwater operations. 
These billets are located in Virginia, Florida, and Southern California. 
The responsibilities will include the care of these personnel and participa- 
tion in the instruction programs. Duty with these units will entail some 
travel, but ordinarily not long absences from the home base. Any who like 
the outdoor life and activities around the water front should enjoy this duty 
particularly well. 

Those assigned will be given an eight-week course of instruction in 
diving medicine which covers diving technic and practices, underwater 
physiology, and the recognition and care of diving casualties. The course 
will be given in Washington, D. C. during July and August. The tour of 
duty is for two years but no extension of service obligation is entailed for 
this training. Applicants from the East Coast are particularly desired. 
Those who are interested are urged to volunteer now to avoid last minute 
confusion over orders. Write to Chief, Bureau of Medicine and Surgery 
(Attn: Code 75), Navy Department, Washington 25, D. C. 

% >\i >i< % % ii= 
Nuclear Power Program 

Training for duty with nuclear powered submarines has been markedly 
shortened and the over all time spent in training and in duty aboard such 
ships has been correspondingly reduced. Experience has demonstrated 
the feasibility of condensing the essential academic work into an intensive 
seven-week program. This will be included in the six months basic training 
in submarine medicine for those going into the nuclear power program. It 
will be followed by a period of practical training at an Atomic Energy Com- 
mission reactor site. Following this, as needed by the submarine building 
program, the doctors will serve aboard nuclear powered submarines. 

The basic six months course in submarine medicine will continue to 
include diving medicine (instead of the radiation biology) for those destined 
to serve with diesel pojvered submarine squadrons and diving organizations. 
This realignment of training is based on experience and the desire to reduce 



32 Medical News Letter, Vol. 33, No. 3 



the over all time commitment. It will not abolish the opportunity for those 
who desire a more extensive academic type of training in radiation biology 
to attend the AFSWP sponsored course nor the postgraduate course at the 
University of Rochester. 

Those entering the nuclear power program via the shorter course may 
expect to be well grounded in the aspects of those problems generally grouped 
under the term "Health physics. " This is a training that will prove useful 
in a practical way in many circumstances a physician will encounter. Anyone 
interested in additional information should write Director, Submarine 
Medicine Division, Bureau of Medicine and Surgery, Washington 25, D. C. 

Diving Medicine 

One morning's mail brought the following: 
Case #1 

International cooperation was displayed at San Diego recently when a 
Mexican scuba diver was flown from Acapulco for treatment aboard the sub- 
marine tender NEREUS. Red tape was slashed to permit his being brought 
in without the usual visas and other arrangements. 

The diver was using an air scuba for a dive to 155 feet. Time of dive 
and decompression schedule are not available. Shortly after surfacing he 
suffered convulsions and was placed in a portable recompression chamber. 
He spent 25 hours in this chamber during which time he was flown to San Diego. 
There he was transferredto the recompre ssion chamber of NEREUS and grad- 
ually decompressed over a period of 60 hours. At the end of decompression he 
was partially paralyzed in one leg and completely paralyzed in the other. 
His comment: "Legs or no legs, I owe my life to the Navy. Let me be a 
good example of why divers should not be careless of safety rules. " 

Congratulations to LT Charles Glazzard MC USNR, Medical Officer, 
Submarine Squadron Three and HM3 Lawrence Stokes, diver corpsman, 
and the personnel on the outside who kept the chamber operating. 

Case #2 

The Calgary Sub Aquatic Club of Calgary, Alberta, checks in with 
this one. While diving in a limestone sink having visibility to 70 feet and a 
depth of 160 feet, a doctor began to feel dizzy at about 90 feet and was next 
observed at 120 feet, tangled in his line, mouthpiece out of his mouth, lying 
motionless. He was brought to the surface quickly and after 3 minutes of arti- 
ficial respiration and two days rest in a hospital "he is all set to go again. " 
Comment: A medical education takes so long and costs so much, one won- 
ders if this doctor had not better take a second look at this business. At least, 
the club is getting some copies of "Submarine Medicine Practice" to read. 



Medical News Letter, Vol. 33, No. 3 



33 



DENTAL 




SECTION 



Mouth Preparation for Removable 
Partial Dentures 



The third in a series of slide lectures prepared by the U. S. Naval 
Dental School, National Naval Medical Center, Bethesda, Md. , is now avail- 
able for loan on a short term basis. This study set consists of 74 35-mm. 
colored slides, a bound narration in lecture form, slide file, hand viewer, 
and carrying case packaged to facilitate their use. Ten sets are available. 

The use of either this material or the previous lectures, Remount 
Technique for Occlusal Correction of Complete Dentures and Non -Neoplastic 
Oral Lesions, should be requested in the manner indicated below: 



From 



To: Commanding Officer, U.S. Naval Dental School (Code 7), National 
Naval Medical Center, Bethesda, Md. 

Subj: Illustrated lecture; request for loan of 

1. It is requested that I be granted the loan of the illustrated lecture 

for approximately two weeks, 

commencing on or about 1959, expiring not later than 

two weeks from the date of receipt. 

2. I will exercise due care in handling and stowing this training material 
and will return it in the original carton with the enclosed franked address 
labels attached, at the expiration of the loan period. 



(Signature) 



34 Medical News Letter, Vol. 33, No. 3 



ADA Members hip Reaches New High 

Membership in the American Dental Association reached 91,488 as 
of November 30, 1958. The figure represented an increase of 2, 184 from 
the same date one year ago and an increase of 2, 143 over the 1957 total 
membership figure of 89, 345. 

$ 3|t % 4t SpB iftt 

Applicants Desired for Dental Technician Training 

Applications are desired for courses of instruction in General Dental 
Technician, Advanced, Class "B" and Prosthetic Dental Technician, Advanced, 
Class "B". Applicants must be qualified in accordance with BuMed Instruction 
1510. 2B. Eligible Technicians will be considered for selection to a class 
convening approximate to their rotational phase in accordance with current 
SHORVEY/SEAVEY procedures. 



Requests are desired from eligible personnel who desire a course of 
instruction in Dental Technician, General (Basic) Class "A" which will lead 
to a change to dental rating. (Reference BuMed Instruction 1510. 6A) 



?!< ?|c ^ ?'£ *'{ ?Je 




RESERVE SECTION 



Annual Meeting of Aero Medical Association 

The Aero Medical Association will hold its 30th Annual Meeting 
at the Statler Hotel, Los Angeles, Calif,, during 27, 28, and 29 April 1959. 

The theme of this meeting will be "Aviation Medicine" with the scienti- 
fic program planned for three full days of sessions on subjects considered 
to be excellent training for all Armed Forces Medical Department officers, 
particularly those whose anticipated mobilization potential is related to 
naval aviation medicine. 

Eligible inactive Reserve Medical Department officers have been auth- 
orized to receive one retirement point credit for each day's attendance, pro- 
vided they register with the military representative present. 

# % ;Jc i$c sj: sj; 



Medical News Letter, Vol. 33, No. 3 35 



Promotion Point Credit 

1. Twelve promotion points are creditable for each fiscal year since 30 June 
1949 in which participation in present grade in the Naval Reserve was at the 
following minimum levels: 

a. Fiscal Year 1958 and subsequently (effective 1 July 1957) : Points 
are creditable for meeting the participation requirement of either subpara- 
graph (1) or (Z) below: 

(1) Completion of 14 days* active duty, active duty for training, 
and/or periods of appropriate duty; or 

(2) Attendance at 75% of drills prescribed (48 or 24 drills) in the 
table of organization for the unit or units in which enrolled, but in no case 
less than 18 drills, Drills attended as an instructor in a Naval Reserve 
officer school are included. Drills attended as a student in a Naval Reserve 
officer school are not included. 

(a) The number of drills attended is the number reported on 
Quarterly Naval Reserve Drill Reports (NavPers 1259). 

(b) An officer's percentage of attendance is determined by 
dividing the total number of drills attended by the total number of drills 
prescribed for the quarters in which the officer is enrolled. If an officer 
is enrolled in more than one unit during a year, the divisor in this compu- 
tation is computed by multiplying the total number of quarters in which he 
was enrolled by the number of drills prescribed per quarter for the unit 
having the least number of prescribed drills. 

b. Fiscal Years 1956 and 1957 (1 July 1955 through 30 June 1957) : 
Minimum participation requirements were the same as in paragraph 1 a above, 
except for the following: 

(1) The minimum number of drills was 12 instead of 18. 

(2) Drills attended as either an instructor or a student in a Naval 
Reserve officer school course were included in drill attendance. 

c. Fiscal Years 1950 through 1955 (1 July 1949 through 30 June 1955 ): 
Completion of the requirements for a year of satisfactory Federal service 
through accrual of 50 retirement points, provided that at least twelve of the 
retirement points were earned by active duty, active duty for training, drills, 
or appropriate duty. For officers having anniversary years other than the 
fiscal year, the twelve points in fiscal year 1955 were creditable for the por- 
tion of a year between anniversary date and 30 June 1955, provided that in 
that period at least 50 retirement points were accrued, at least twelve of 
which were earned by active duty, active duty for training, drills, or appro- 
priate duty. (BuPers Inst. 1416. 4B) 

^ ^ ^t ^ t ^ 



36 Medical News Letter, Vol. 33, No. 3 




$}> PREVENTIVE MEDICINE SECTION 



Parasitic Infestations 

There can be no doubt that a parasitic mode of life presents certain 
attractions: for one thing, there is the guarantee of a comfortable climate 
with equable temperatures at all times of the year; again, there is no need 
for foraging, or for work of any kind— nothing to do but to feed, grow, and 
reproduce the species in which direction most parasites are very highly 
successful. There is one species of nematode in the rat, the male of which 
actually lives as a parasite inside the uterus of the female. Progeny in most 
instances are born in astronomical numbers; in the case of Ascaris lumbri- 
coides, some 200,000 eggs are produced per day. All of this was intended 
for the sparsely scattered communities of early times and one source of 
trouble over the attempted eradication is the enormously enhanced seeding 
of infection due to the crowding of animals under agricultural conditions. 

In view of the slender chance of meeting another host, it is necessary 
for all parasitic worms to be able to await their time, a propensity which is 
achieved in a surprising number of different ways. The example that has 
just been used, A. lumbricoides, follows one of the rather ordinary ways in 
that the eggs which it produces, after they have become embryonated, are 
exceedingly resistant to the effect of adverse conditions so that they may 
wait for months or, under optimum conditions, even for years (12-1/2 years 
in experimental observations at Weybridge) for the arrival of that lucky 
chance when they are ingested by a pig or a man. 

Another way to tide over a period of waiting is for the larval worm to 
enter into an invertebrate intermediate host, as do some of the exotic flukes 
that are able to infest both man and animals; those infective forms are able 
to wait indefinitely during the life of the intermediate host. And the lives 
of some of these invertebrate creatures are much longer than is popularly 
supposed; for example, the earthworm, Lumbricus terrestris, is thought to 
have a span of life of some 10 years, throughout which time it may carry 
certain nematode infections. 

Yet another way in which larval worms tide over a period of waiting 
for a new host is to develop to a certain stage in the body of a vertebrate 
intermediary and await the attack of a carnivore. Itis in this voracious way 



Medical News Letter, Vol. 33, No. 3 37 



that man becomes infested with his two large tapeworms, Taenia saginata 
and T. solium. There could be no more certain evidence than this to meet 
the vehement arguments of some food-reform friends that man was originally 
a vegetarian. These guests have nowhere other than in man to live and their 
association with him must go back through millions of years of his subsis- 
tence on the flesh of pigs and cattle. 

One curious point should not be overlooked — that in no instance is it 
possible for these parasites to give rise to successive generations in one 
and the same host; a new host must always be found in which the worm may 
grow to maturity. It follows, therefore, that every individual worm must 
spend some time between hosts; it is here that the sanitarians have their 
opportunity to put an obstacle in the way of transference. 

One other character which helps these parasites to keep a footing in 
civilization is the length of the lives of parasitic individuals. This is very 
surprising, there being good evidence to show that some individual represen- 
tatives of T. saginata may live for 30 to 40 years: human hookworms are 
known to live for some 12 years and the human blood fluke Schistosoma 
mansoni up to 40 years. During the whole of their long lives, these parasites 
are disseminating infective material at a tremendous rate. 

It is of some practical importance that infected persons, after one or 
two unsuccessful attempts to rid then] selves of their taenoid companions, 
may be content to carry them for years, or that in some instances, they 
may not be aware of their infestation. One of the privileges of a parasitolo- 
gist is to carry out experiments on himself; because his guest will not burden 
him with a family, he knows that he will house no more than the invited num- 
ber. In illustration of this point of unawareness, JLeiper made a report of 
three experimentalists who, for the purpose of studying the anemia associa- 
ted with infection of Diphyllobothrium latum, swallowed the viable plerocer- 
coids from fish caught in the Swiss lakes. At the end of the experimental 
period, antihelminthic treatment was applied and complete worms were 
recovered corresponding to the numbers of plerocercoids swallowed in all 
but one case where only three worms were expelled although four plerocer- 
coids had been swallowed.' As the infective stages of parasites often fail to 
develop in the experimental host there was nothing remarkable about recover- 
ing one fewer than had been put in and this individual host thought himself 
freed from the infection. It was surprising, therefore, to discover 5 years 
later that the worm was still there. 

In the same connection, Dr. P. A. LeKoux has communicated a per- 
sonal observation of a living tapeworm segment having been seen by him 
to fall from the clothing of a man while playing an outdoor game. In common 
with some other cestode segments, those of T. saginata behave almost like 
individual organisms, crawling away from a fecal mass, or as in this instance, 
making their way independently through the anal sphincter and into the environ- 
ment of the host. This constitutes one of the important ways in which infection 



38 Medical News Letter, Vol. 33, No. 3 



may be widely distributed and it easy to see how farm workers carrying 
T. saginata, for instance, may distribute the segments onto the pastures 
perhaps over a period of years as they go about their daily work. 

While it is for the medical profession to improve existing methods 
and apply treatment for the eradication of these cestode parasites from 
infected individuals, it is for the veterinarians and the sanitarians to direct 
their attention to the application and the improvement of known means of 
preventing the transference of these parasites from animal to human host. 
(Taylor, E. L, , D. V. Sc. , Symposium on Some Lesser-Known Diseases 
Common to Man and Animals; (a) Parasitic Infestations: Roy. Soc. Promot. 
Health J. , 78: 664-665, September - October 1958) 

s{c :{« Jf If. if % 

Resistance of Beta-Hernolytic Streptococci 
to Tetracycline 

The tetracycline drugs have been referred to frequently as alternatives 
in the treatment of beta-hemolytic streptococcal infections in those cases 
hypersensitive to penicillin or erythromycin. This article demonstrates 
that strains of Group A, Type 12 streptococci have appeared which are 
resistant in vitro to therapeutic levels of tetracycline. 

The oldest child of a family of six developed fever, slight sore throat 
without dysphagia, and nonproductive cough 3 days after a coryzal illness 
that involved all members of the family. Examination of the throat revealed 
only moderately enlarged tonsils and nontender anterior cervical lymph- 
adenopathy. Because a throat culture taken during the previous illness 
was negative for beta-hemolytic streptococci, therapy was begun with tetra- 
cycline, 750 mg. per day, and continued for 5 days. Throat cultures taken 
on the first, third, and seventh days after onset all contained numerous 
colonies of beta-hemolytic streptococci which were classified as belonging 
to the viridans type because of the lack of reaction with grouping sera, 
minimal degree of hemolysis and marked resistance to tetracycline. One 
week after the onset of this illness, three other members of the family 
developed fever and moderate sore throat. Pharyngeal cultures all con- 
tained numerous colonies .of beta-hemolytic streptococci, Group A, Type 12, 
sensitive to penicillin and erythromycin but resistant to all tetracycline 
drugs. 

Because of the occurrence of another family outbreak in which tetra- 
cycline therapy failed to relieve symptoms, a culture survey was done in 
the school attended by children from both households. From a total of 131 
cultures, Group A streptococci were isolated in 40. Thirty-eight of these 
strains were Type 12 that were found to be resistant to tetracycline, oxy- 
tetracycline, or chlortetracycline in concentrations greater than 30 mgm. 



Medical News Letter, Vol. 33, No. 3 39 



Streptococcal isolations were done on 5% sheep blood agar plates. 
Antibiotic sensitivity was initially determined on all strains by the disc 
method. Representative strains were studied further by the tube-dilution 
technique with purified antibiotics. The Type IE strains isolated were all 
resistant to tetracycline concentrations of 50 mgm. but were sensitive to 
penicillin and erythromycin. This preponderance of tetracycline resistant 
strains indicated that widespread dissemination in the population had prob- 
ably occurred. 

The practice of empirical treatment of upper respiratory disease with 
tetracycline drugs because of their "broad spectrum" activity is common- 
place. Because of the previous uniform susceptibility of Group A strepto- 
cocci to all of the antibacterial drugs, except sulfonamides, in wide use 
the antibiotic sensitivity of beta-hemolytic streptococci has not usually been 
determined. It appears that such information is necessary if tetracycline 
therapy is proposed. The continued appearance of resistant strains may 
be expected in view of the common usage of the tetracyclines. (Mogabgab, 
W. J. , Pelon, W. , Ph. D. , An Outbreak of Pharyngitis Due to Tetracycline - 
Resistant Group A, Type 12 Streptococci: J. Dis. Child. , 96: 696-698, 
December 1958) 

****** 

Effect of Alcohol on Risk Taking in Driving 

A group of bus drivers in Manchester, England, were studied to deter- 
mine the effect of alcohol on their judgment concerning their belief in their 
ability to recognize driving hazards and risks. The conclusions reached were: 

1. Drivers who took alcohol became involved in greater hazards than 
alcohol-free drivers. 

2. As the amount of alcohol taken was increased, the drivers were 
prepared to drive their vehicles through narrower gaps. This revealed 
that the alcohol adversely affected their judgment, 

3. The performance of the drivers as well as their judgment, pro- 
gressively deteriorated as they consumed more alcohol. 

4. After taking alcohol the drivers became more dangerous, although 
they did not take greater risks. This was due to the fact that the level 

of confidence above which they were prepared to drive remained unchanged; 
but at any given size of gap the drivers after taking alcohol were more con- 
fident of success and thus prepared to drive through narrower gaps. 

5. Alcohol intensified any drivers' tendency to overrate his ability in 
relation to his performance. 

(Cohen, J. , Ph. D. et al. The Risk Taken in Driving under the Influence of 
Alcohol: Brit. Med. J., No. 5085 : 1438-1442, June 21, 1958) 



40 



Medical News .Letter, Vol. 33, No. 3 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

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